Caregivers for children with chronic medical conditions face a care journey that can be summed up by the word “fragmentation,” according to Abe Sutton, who directs the Center for Medicare and Medicaid Innovation (CMMI) and is deputy administrator for the Centers for Medicare & Medicaid (CMS).
There are school services, outside social workers, medical doctors, subspecialists, occupational therapists.
Busy parents are coordinating all of these visits with school schedules and work schedules. They sometimes face transportation issues.
Yet there is no one at the center that takes time to help families navigate the system, he said during an interview with AMA CEO and Executive Vice President John Whyte, MD, MPH, for an episode of the “AMA Moving Medicine” video podcast.
That is why CMS has unveiled a plan to transform how Medicaid supports high-risk children in the program, including a voluntary new model to pay physicians for their efforts in treating these pediatric patients.
The new CMS model—called Accelerating State Pediatric Innovation Readiness Effectiveness (ASPIRE)—redefines priorities, payment and accountability for pediatricians and subspecialties. It also challenges states to embrace a new standard of care.
“Our goal in ASPIRE is to give a coordinated approach for the 23% of Medicaid children with high- and rising-risk so that their families are not flying blind in the system,” Sutton said. “What they are instead doing is going to a system where somebody is holding their hand and guiding them through it.”
He said it will allow CMS to spend more effectively, without increasing existing costs in the system, all while transforming families’ experiences as they interact with the health care system.
The program is directed to help children with chronic medical conditions, including those with behavioral conditions—for example, children with autism—where caregivers are trying to manage coordinating care from numerous physicians and health professionals. CMS is looking to partner with states that choose to apply to be part of the program and then customize the program for a given state and its population.
The ASPIRE program aims to:
- Ensure patients and their caregivers have a care coordinator, such as a social worker or other professional who can help caregivers navigate the complex system and find the right supports for their child.
- Encourage states to offer 24/7 access to someone who can answer care givers questions that arise at any time in the day or night.
- Use an accountable care organization (ACO) approach so that pediatricians and specialists are encouraged to structure and deliver care that proactively looks out for Medicaid patients who are high -risk patients and pays physicians for the actions they need to take to change patient outcomes for the better.
“It’s ACO to care for kids with chronic disease,” Sutton said, adding that CMS would like states to come forward to partner with the agency to find the best structures to meet an individual state’s needs. He said it is important to CMS that there be financial rewards to encourage the activity, the coordination and the transmittal of data so that families have more support.
In a statement, Dr. Whyte said that “CMS has embraced the challenge of transforming how families experience the health care system. Families enrolled in Medicaid face abundant obstacles to care—transportation, babysitting, coordination and navigating next steps. Giving families a locus of care and building in flexibility could improve the coordination for many vulnerable populations.
Dr. Whyte added that “Abe Sutton and his team have demonstrated a deep understanding of these challenges and strong commitment to addressing them. Physicians are eager to join this effort.”
New ways to deliver pediatric care
On the AMA podcast, Sutton said he “would envision a pediatrician coming forward, a pediatric practice, and saying: All right, we want to deliver care for the patients that we care for in a different way. Let’s take on this accountability for spending. Let’s be tracked on the core quality outcomes that matter. Give me the information. Give me the advanced cash flows so I can support this and, over time, I’m willing to take on accountability for the cost of outcomes,” Sutton said.
And for those who are skeptical about another model based on value-based care, Sutton said that physicians would not be taking on financial risk at the beginning of the journey and that CMS needs to help ensure that pediatricians are empowered.
“We are looking at a multiyear model,” he said. “First, we are going to partner with a state that chooses to apply or multiple states that choose to apply and we’ll set up a structure where they’re building up infrastructure—building blocks—to support pediatricians or managed care entities. … In addition to that, we will be sharing data and tools to help manage the population to support in this journey.”
Sutton added that the model sets up a structure that enables physicians to practice in the right way.
“It’s not people in Washington determining you should deliver this service or that service,” he said. Instead, it is CMS “identifying core things that we know make a difference, giving you flexibility in how to do that and then stepping back and saying: ‘What other wraparound do you need?’”
Physician-focused CMS models
ASPIRE is just one of the new models that CMS has unveiled in the past year. Last year, CMS launched a voluntary imitative to test technology-supported care for traditional Medicare patients with chronic conditions called the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model.
CMS also introduced a new ACO model called Long-term Enhanced ACO Design (LEAD). It is designed to provide a better way for primary care physicians and specialists to work more closely together to deliver high-quality, coordinated care for patients—something the AMA has recommended for several years (PDF).
Visit AMA Advocacy in Action to find out what’s at stake in reforming Medicare payment and other advocacy priorities the AMA is actively working on.
